Just Plain Ruff Posted November 9, 2008 Posted November 9, 2008 from same article referenced lightning strikes show on the 12 Lead as peaked T-waves. here's the quote Pertinent data: EKG on arrival to the community hospital revealed sinus tachycardia with a normal axis, and peaked T waves in the precordial leads V2–V4 (Fig. 2). Twenty-four hours later, EKG revealed normal sinus rhythm with high QRS voltage and early repolarization.
chbare Posted November 9, 2008 Author Posted November 9, 2008 Weather is sunny and boring blue. Your partner seems a bit concerned about the patient's pressure, or lack of pressure in this case. Take care, chbare.
AnthonyM83 Posted November 10, 2008 Posted November 10, 2008 Can you get a pressure on the opposite arm? Skin signs, cap refill...aka perfusion signs? Move to lidocaine? And can we get a manager/foreman to secure the scene and find out what kind of electrical sources were up there?
hammerpcp Posted November 10, 2008 Posted November 10, 2008 Can we have a full update on pt status? and disrobe the pt. While maintaining (or initiating) spinal immobilization assess: LOC, is he a GCS of 3? Any spontaneous respirations? Lung sounds/ chest rise? Vitals at the moment are: RR- assisted @ 10-12/min, HR - about 70 with Paroxysmal VT (how long are these runs? What is the rate and does he have a pulse? Some amiodarone might help) BP- 70 systolic (Can we try and fix this? let's give him a fluid bolus) Skin is?? SpO2 is 90% or thereabouts with assisted ventilations ETCO2 is?? Now that we have slowed down the ventilatory rate? Pupils are dilated and sluggish to constrict CBG is?? Are there any other injuries noted? What does a secondary exam tell us?
chbare Posted November 11, 2008 Author Posted November 11, 2008 GCS: 3 No spontaneous respiratory activity. Unable to obtain a pulse oximetry waveform. ETCO2 is currently 28. Hard to get a pressure in the other arms as it is obviously deformed mid humerous. Clear lung sounds with equal bilateral chest rise and fall noted. Skin is pale. BGL: 112mg/dl Additional assessments are unchanged from the findings stated above. Current pulse is 120 weak and irregular at the carotid. You note approx three to four 7 complex runs of unifocal ventricular tachycardia per minute. How much fluid will we give? Lidocaine versus Amiodarone? What do you all think? Still waiting on a scene update. Labs: WBC: 15 HBG: 15 HCT: 45 NA: 133 K: 5.4 CL: 102 BUN: 30 Creat: 3 Myoglobin: 570 CK: 1000 CKMB: Pending Trop: Pending What do you want done at the ER? Take care, chbare.
Arizonaffcep Posted November 11, 2008 Posted November 11, 2008 How much fluid will we give? Lidocaine versus Amiodarone? What do you all think? Lido vs Amio...simple for me...we don't carry amio, so that kinda narrows it down . I tend to dose Lido at 1mg/kg bolus with a drip of .5mg/kg (easier math). Labs: WBC: 15 HBG: 15 HCT: 45 NA: 133 K: 5.4 CL: 102 BUN: 30 Creat: 3 Myoglobin: 570 CK: 1000 CKMB: Pending Trop: Pending Correct me if I'm wrong, but his myoglobin and CK are elevated. Couple this with increased K, BUN, & Creat., I am seeing rhabdo on the not-to-distant horizon. So, fluid wise, start no less than 2 large bore iv's, one with NS for blood (although some recent studies show LR undoctored does NOT cause clotting with donor whole blood[sup:188a857b60]1[/sup:188a857b60]), and 1 LR, running at the "20ml/kg bolus," which in reality would run wide open for no less than 3 liter. I'd even consider an albuterol tx to help shift the K and see if that changes his rhythm before lido. Get him to a trauma center, even better if it also has a burn unit. [sup:188a857b60]1[/sup:188a857b60]http://findarticles.com/p/articles/mi_m3225/is_n2_v58/ai_21038661
chbare Posted November 11, 2008 Author Posted November 11, 2008 Good job everybody. I think people realized the cause pretty early on in this scenario. However, I wanted to discuss things further before giving the cause away. Initially, we were presented with a trauma scenario; however, additional investigation led us to suspect other problems than a simple fall. During the patient's course, he in fact develops rhabdo and has continued hemodynamic instability. Fluids along with pressors are needed to "stabilize" his pressure. After the first couple of days, he ends up developing compartment syndrome of the extremities and require surgical intervention. You have him "stabilized" in the ICU following the said interventions when you note decreased urinary output and increased ventilatory pressures. What do you think? Take care, chbare.
AZCEP Posted November 22, 2008 Posted November 22, 2008 Time for a fasciotomy or three. Compartment syndrome is going to destroy our ability to ventilate, and his ability to perfuse.
Laura Anne Posted November 22, 2008 Posted November 22, 2008 Sooooo, do we know anything about his health over the past fews days prior to the event? Is he on a diet? Has he been over-doing it at work...straining himself on the project? Due to his abnormal labs and rhabdo, they may be pointing in the direction of CPTII...?? :roll: just a guess 8)
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